Form PR/LA Page 1 of 2 (Rev. 12/09) Elaine F. Marshall, Secretary of State Principal Registration and Lobbyist Authorization Statement 2010 Principal Information Complete Name of Principal:*_________________________________________________________________ Business Address of Principal (Physical NOT a P.O. Box):__________________________________________ Name of Principal’s Authorized Officer:_________________________________________________________ Title of Principal’s Authorized Officer:__________________________________________________________ Mailing Address of Principal’s Authorized Officer:________________________________________________ Telephone No. of Principal’s Authorized Officer:__________________________ Fax:____________________ E-Mail Address of Principal’s Authorized Officer (see ** below):_____________________________________ Optional secondary e-mail address (Example: Administrative Assistant): ________________________________________________ Principal Legal Structure:(Check One) NC Corporation Limited Liability Company Unincorporated Association Foreign Corporation _____________________ (Foreign State of Incorporation). If the entity is an unincoporated association, the authorized officer will need to provide a list of all officers. Please attach the list to this registration. I wish to add additional authorized officers and have attached Form AAOS-10. Lobbyist Information Complete Name of Lobbyist:__________________________________________________________________ Firm Name of Lobbyist (If Applicable):__________________________________________________________ Business Address of Lobbyist (Physical NOT a P.O. Box):__________________________________________ Mailing Address of Lobbyist:__________________________________________________________________ Telephone No. of Lobbyist:__________________________________Fax No.___________________________ E-Mail Address of Lobbyist:___________________________________________________________________ Optional secondary e-mail address (Example: Administrative Assistant): _________________________________________ *The principal is the entity or person, as defined in N.C.G.S. §120C-100(a)(11) on whose behalf the lobbyist influences or attempts to influence legislative and/or executive action. The authorized officer is the person designated by the principal to act as the contact person for all lobbying activities. Information included on this form should correspond to information provided on the Lobbyist Registration Statement (Form LR-RS). ** If you do not provide an email address on this form and do not mark the box to receive notices in another format (see box below), we are under no obligation to inform you of report due dates, form changes, or any other information we provide via these methods.  Check if attaching Form RW, Application for Waiver/Reduction of Registration Fees for 26 U.S.C. 501(c)(3). Note: see page 2 of RW form for fee amount. Registrations submitted without correct fee will be rejected. The Division will send notices regarding filing due dates electronically at no charge. If you desire to receive notices from our office in another format, please indicate that by checking the box and you will be invoiced according to N.C.G.S. §132-1(b). American LegalNet, Inc. www.FormsWorkFlow.com Form PR/LA Page 2 of 2 (Rev. 12/09) CERTIFICATION I hereby certify that all information disclosed in this “Principal Registration and Lobbyist Authorization Statement 2010” is true, complete and correct in accordance with N.C.G.S. §120C-206, and authorize the above named lobbyist to lobby on behalf of the Principal for the calendar year 2010. By signing this certification, I understand the principal through its authorized officer or representative has an affirmative duty to understand the rules and to comply with the Lobbying Law, including filing reports as the law requires. _____________________________________________________ Signature of Principal’s Authorized Officer _________________ Date (Complete only if Preparer is NOT Authorized Officer) Report Preparer’s Identity/Signature (18 NCAC 12 .0209) Printed Complete Name of Report Preparer: ______________________________________________________ Signature of Report Preparer: _________________________________________________________________ • • • This form must be filed by all principals who have employed or retained a lobbyist within 20 business days after a Lobbyist Registration Statement has been filed with the Secretary of State. Information on this form should correspond to information provided in the Lobbyist Registration Statement (Form LR-RS). Registrations are effective from the date of filing until January 1 of the following year unless written notification is received prior to that date. The principal shall file a new registration statement after that date. The fee of one hundred dollars ($100.00) is due and payable to the Secretary of State when the principal’s FIRST Registration/Authorization statement is filed each calendar year for a lobbyist under N.C.G.S. §120C207(a). FILING SUBMISSION LOCATIONS AND METHODS Each required filing shall be submitted to the Department by one of the following methods: (1) By United States mail at the following address: Lobbying Compliance Division Department of the Secretary of State P. O. Box 29622 Raleigh, N.C. 27626-0622 (2) By hand-delivery or by a designated delivery service authorized pursuant to N.C.G.S. 1A-1, Rule 4 at the following street address: Lobbying ComplianceDivision Department of the Secretary of State 2 South Salisbury Street Raleigh, N.C. 27601-2903 (3) Electronically by electronic mail at the following address: lobbyistfiling@sosnc.com. Any document(s) attached to the filing other than the form or report shall be compatible with or convertible to the most recently issued version of Microsoft Word®; or (4) By facsimile (919-807-2205) for filings not requiring a fee, provided the original signed document is postmarked or delivered to the Department within seven days following the Department's receipt of the faxed transmission. A filing for which the original is not postmarked or delivered to the Department within seven days following the Department's receipt of the faxed transmission is void. A document received by hand-delivery or fax after 5:00 p.m. is considered to be received on the following day. NOTE: REGISTRATION TRIGGERS REPORTING OBLIGATIONS. QUARTERLY REPORTS MUST BE FILED REGARDLESS OF WHETHER THERE ARE ANY REPORTABLE EXPENDITURES. For each quarter a principal is registered, the authorized officer is obligated to file a quarterly expense report and may be obligated to file monthly expense reports when necessary. For further explanation of regulations and guidelines, see Lobbying Guidelines -- General Information (Form LR-GI) DO NOT USE THIS FORM IF YOU ARE REGISTERING FOR ECONOMIC INFORMATION PROTECTION. American LegalNet, Inc. www.FormsWorkFlow.com